A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED
Patient’s Last Name
Physician Orders for Scope of Treatment (POST)
This is a Physician Order Sheet based on the medical conditions and
wishes of the person identified at right (“patient”). Any section not
completed indicates full treatment for that section. When need
occurs, first follow these orders, then contact physician.
Section
A
Check One
Box Only
Section
B
Check One
Box Only
First Name/Middle Initial
Date of Birth
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and/or is not breathing.


Resuscitate (CPR)
Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C, and D.
MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.
 Comfort Measures. Treat with dignity and respect. Keep clean, warm, and dry. Use medication by any route,
positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of
airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer
only if comfort needs cannot be met in current location.
 Limited Additional Interventions.
Includes care described above. Use medical treatment, IV fluids and cardiac
monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
Transfer to hospital if indicated. Avoid intensive care.
 Full Treatment.
Includes care above. Use intubation, advanced airway interventions mechanical ventilation, and
cardioversion as indicated. Transfer to hospital if indicated. Include intensive care.
Other Instructions:
Section
C
Check One
Box Only
Section
D
Check One
Box Only in
Each
Column
Section
E
Must be
Completed
ANTIBIOTICS – Treatment for new medical conditions:
 No Antibiotics
 Antibiotics
Other Instructions:
MEDICALLY ADMINISTERED FLUIDS & NUTRITION. Oral fluids & nutrition must be offered if medically feasible.
 No IV fluids (provide other measures to assure comfort)
 IV fluids for a defined trial period
 IV fluids long-term if indicated
Other Instructions:
Discussed with:
 Patient/Resident
 Health care agent
 Court-appointed guardian
 Health care surrogate
 Parent of minor
 Other:
Physician Name (Print)
 No feeding tube
 Feeding tube for a defined trial period
 Feeding tube long-term
The Basis for These Orders Is: (Must be completed)
 Patient’s preferences
 Patient’s best interest (patient lacks capacity or preferences unknown)
 Medical indications
 (Other)
(Specify)
Physician Signature (Mandatory)
Date
Physician Phone Number
Signature of Patient, Parent of Minor, or Guardian/Health Care Representative
Preferences have been expressed to a physician /or health care professional. It can be reviewed and updated at any time if your preferences change.
If you are unable to make your own health care decisions, the orders should reflect your preferences as best understood by your surrogate.
Name (print)
Signature
Relationship (write “self” if patient)
Surrogate
Relationship
Phone Number
Health Care Professional Preparing Form
Preparer Title
Phone Number
November, 2012 (Revised)
Date Prepared
HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Directions for Health Care Professionals
Completing POST
Must be completed by a health care professional based on patient preferences, patient best interest, and medical
indications.
POST must be signed by a physician to be valid. Verbal orders are acceptable with follow-up signature by
physician in accordance with facility/community policy.
Photocopies/faxes of signed POST forms are legal and valid.
Using POST
Any incomplete section of POST implies full treatment for that section.
No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation”.
Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, the person, including someone with “Comfort
Measures Only”, should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only”.
Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate
“Limited Interventions” or “Full Treatment”.
A person with capacity, or the surrogate of a person without capacity, can request alternative treatment.
Reviewing POST
This POST should be reviewed if:
(1) The patient is transferred from one care setting or care level to another, or
(2) There is a substantial change in the patient’s health status, or
(3) The patient’s treatment preferences change.
Draw line through sections A through E and write “VOID” in large letters if POST is replaced or becomes
invalid.
COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.
November, 2012 (Revised)